288 Diagnostic Categories
`
`of a preexisting physical condition, as in the aCCeptance of a- penicillin injection
`despite a known previous history of an anaphylactic reaction; or any combina-
`tion or variation of the above.
`
`301.51 Chronic Factitious Disorder with Physical Symptoms
`The essential feature is the individual’s plausible presentation of factitious
`physical symptoms to such a degree that he or she is able to obtain and sustain
`multiple hospitalizations. The individual’s entire life may consist of either try—
`ing to get admitted into or staying in hospitals. Common clinical pictures in—
`clude severe right lower quadrant pain associated with nausea and vomiting,
`dizziness and blacking out, massive hemoptysis, generalized rash and abscesses,
`fevers of undetermined origin, bleeding secondary to ingestion of anticoagulants,
`and ”lupuslike” syndromes. All organ systems are potential targets, and the
`symptoms presented are limited only by the individual’s medical knowledge,
`sophistication, and imagination. This disorder has also been called Miinchausen
`syndrome.
`their history with great dramatic flair,
`These individuals usually present
`but are extremely vague and inconsistent when questioned in more detail. There
`may be uncontrollable pathological lying, in a manner intriguing to the listener,
`about any aspect of the individual’s history or symptomatology (pseudologica
`fantastica). These individuals often have extensive knowledge of medical
`terminology and hospital routines. Once admitted to a hospital they can create
`havOc on the ward by demanding attention from hospital staff and by non-
`compliance with hospital routines and regulations. After an extensive work-up
`of their initial chief complaints proves negative,
`they will often complain of
`other physical problems and produce more factitious symptoms. Complaints of
`pain and requests for analgesics are very common. Individuals with this dis-
`order often eagerly undergo multiple invasive procedures and operations.
`While in the hospital they usually have few visitors. When confronted with
`evidence of their factitious symptoms they either deny the allegations or rapidly
`discharge themselves against medical advice. They will frequently be admitted
`to another hospital the same day. Their courses of hospitalizations often take
`them to numerous cities, states, countries, and even different continents. Eventu-
`ally a point is usually reached at which the individual is ”caught" producing
`factitious symptomatology; he or she is recognized by someone from a previous
`admission or another hospital, or other hospitals are contacted and confirm
`multiple prior hospitalizations for factitious symptomatology.
`
`Associated features. Substance abuse, particularly of analgesics and seda-
`tives, often medically prescribed, may be present.
`
`Age at onset and course. Onset is usually in early adult life, often with a
`hospitalization for true physical illness. Rapidly thereafter, a pattern of suc-
`cessive hospitalizations begins and becomes a lifelong pattern.
`
`Impairment. This disorder is extremely incapacitating. The course of chronic
`hospitalizations is obviously incompatible with the individual’s maintaining
`
`301
`
`301
`
`

`

`Factitious Disorders
`
`289
`
`steady employment, maintaining family ties, and forming lasting interpersonal
`relationships.
`
`Complications. These individuals frequently acquire a “gridiron abdomen”
`from the multiple surgical procedures they have undergone. Multiple hospital-
`izations frequently lead to iatrogenically-induced physical illness, such as scar
`tissue formation from unnecessary surgery, abscesses from numerous injections,
`and adverse drug reactions. Occasionally they will spend time in jail because of
`vagrancy, or assault in mental hospitals because of transfers from general hospi-
`tals when the factitious nature of their symptoms is discovered.
`
`Predisposing factors. These may include true physical disorder during child-
`hood or adolescence leading to extensive medical treatment and hospitalization :
`a grudge against the medical profession, sometimes due to previous medical
`mismanagement; employment in the medical field as a nurse, technician, or other
`paraprofessional; underlying dependent, exploitative, or masochistic personality
`traits; an important relationship with a physician in the past, e.g., a family mem-
`ber who was a physician, or seduction by a physician during childhood or adoles-
`cence.
`
`Prevalence. Some believe the disorder is cormnon but rarely recognized.
`Others believe that it is rare and that the few individuals with the disorder are
`
`being overreported because they appear to different physicians at different hospi-
`tals, often using different names.
`
`Sex ratio. The disorder is apparently more common in males.
`
`Familial pattern. No information.
`
`Differential diagnosis. The major diagnostic consideration is obviously true
`physical disorder. A high index of suspicion for Chronic Factitious Disorder with
`Physical Symptoms should be aroused if any combination of the following is
`noted: pseudologica fantastica, with emphasis on the dramatic presentation; dis-
`ruptive behavior on the ward, including noncompliance with hospital rules and
`regulations and arguing excessively with the nurses and physicians; extensive
`knowledge of medical
`terminology and hospital routines; continued use of
`analgesics for “pain”; evidence of multiple surgical interventions, e. g., a “gridiron
`abdomen” or burr holes in the skull; extensive history of traveling; few, if any,
`visitors while hospitalized,- and a fluctuating clinical course with the rapid pro-
`duction of “complications” or new ”pathology" once the initial work-up proves
`to be negative.
`In Somatoform Disorders there are also physical complaints not due to true
`physical disorder. However,
`the symptOm production is not under voluntary
`control, and admissions to hospitals are rarely as common as in Chronic Facti-
`tious Disorder with Physical Symptoms.
`Individuals with Malingering may seek hospitalization by producing symp-
`toms in attempts to obtain compensation, evade the police, or simply “get a
`
`302
`
`302
`
`

`

`290 Diagnostic Categories
`
`bed for the night.” However, the goal is usually apparent, and they can “stop"
`the symptom when it is no longer useful to them,
`Antisocial Personality Disorder is often incorrectly diagnosed on the basis
`of the pseudologica fantastica, the lack of close relations with others, and the
`occasionally associated drug and criminal histories. Antisocial Personality Dis-
`order differs from this disorder by its earlier onset and its rare association with
`chronic hospitalization as a way of life.
`Schizophrenia is often incorrectly diagnosed because of the bizarre life-style.
`However,
`the characteristic psychotic symptoms of Schizophrenia are not
`present.
`
`Diagnostic criteria for Chronic Factitious Disorder with Physical Symptoms
`A. Plausible presentation of physical symptoms that are apparently under
`the individual’s voluntary control to such a degree that there are multiple
`hospitaiizations.
`
`is apparently to assume the “patient" role and
`B. The individual’s goal
`is not otherwise understandable in light of the individual’s environmental
`circumstances (as is the case in Malingering).
`
`300.19 Atypical Factitious Disorder with Physical Symptoms
`This is a residual category fer Factitious Disorders with Physical Symptoms
`that do not fulfill
`the criteria for Chronic Factitious Disorder with Physical
`Symptoms.
`Usually individuals with Atypical Factitious Disorder with Physical Symp-
`toms do not require hospitalization. Examples include dermatitis artifacta {in-
`duced by excoriation or chemicals} and voluntary dislocation of the shoulder.
`
`303
`
`303
`
`

`

`Disorders of Impulse Control
`Not Elsewhere Classified
`
`that are
`This is a residual diagnostic class for disorders of impulse control
`not classified in other categories, e.g., as a Substance Use Disorder or Paraphilia.
`The essential features of disorders of impulse control are:
`1. Failure to resist an impulse, drive, or temptation to perform some act
`that is harmful to the individual or others. There may or may not be conscious
`resistance to the impulse. The act may or may not be premeditated or planned.
`
`2.. An increasing sense of tension before committing the act.
`3. An experience of either pleasure, gratification, or release at the time of
`committing the act. The act is ego-syntonic in that it is consonant with the im-
`mediate conscious wish of the individual. Immediately following the act there
`may or may not be genuine regret, self-reproach, or guilt.
`This class contains five specific categories: Pathological Gambling, Klepto-
`mania, Pyromania, Intermittent Explosive Disorder, and Isolated Explosive
`Disorder. Finally, there is a residual category, Atypical Impulse Control Dis-
`order.
`
`312.31 Pathological Gambling
`im-
`The essential
`features are a chronic and progressive failure to resist
`pulses to gamble and gambling behavior that compromises, disrupts, or damages
`personal, family, or vocational pursuits. The gambling preoccupation, urge, and
`activity increase during periods of stress. Problems that arise as a result of the
`gambling lead to an intensification of the gambling behavior. Characteristic
`problems include loss of work due to absences in order to gamble, defaulting on
`debts and other financial responsibilities, disrupted family relationships, borrow-
`ing money from illegal sources,
`forgery,
`fraud, embezzlement, and income
`tax evasion.
`
`Commonly these individuals have the attitude that meney causes and
`is also the solution to all their problems. As the gambling increases, the indi-
`vidual is usually forced to lie in order to obtain mOney and to continue gambling,
`but hides the extent of the gambling. There is no serious attempt to budget or
`save money. When borrowing resources are strained, antisocial behavior in order
`to obtain money for more gambling is likely. Any criminal behavior—e.g.,
`forgery, embezzlement, or fraud—is typically nonviolent. There is a conscious
`intent to return or repay the money.
`
`Associated features. These individuals most often are overconficlent, some-
`what abrasive, very energetic, and "big spenders”; but there are times when they
`show obvious signs of personal stress, anxiety, and depression.
`
`291
`
`304
`
`304
`
`

`

`292 Diagnostic Categories
`
`Age at onset and course. The disorder usually begins in adolescence and
`waxes and wanes, tending to be chronic.
`
`Impairment. The disorder is extremely incapacitating and results in failure
`to maintain financial solvency or provide basic support for oneself or one’s family.
`The individual may become alienated from family and acquaintances and may
`lose what he or she has accomplished or attained in life.
`
`Complications. Suicide attempts, association with fringe and illegal groups,
`and arrest for nonviolent crimes that may lead to imprisonment are among the
`possible complications.
`
`Predisposing factors. These may include: loss of parent by death, separa-
`tion, divorce, or desertion before the child is 15 years of age,- inappropriate
`parental discipline (absence, inconsistency, or harshness]; exposure to gambling
`activities as an adolescent; a high family value on material and financial symbols;
`and lack of family emphasis on saving, planning, and budgeting.
`
`Prevalence. No information.
`
`Sex ratio. The disorder is apparently more common among males than
`females.
`
`Familial pattern. Pathological Gambling and Alcoholism are more common
`in the fathers of males and in the mothers of females with the disorder than in
`the general population.
`
`Differential diagnosis. In social gambling, gambling with friends is engaged
`in mainly on special occasions and with predetermined acceptable losses.
`During a manic or hypomanic episode loss of judgment and excessive
`gambling may follow the onset of the mood disturbance. When manic-like mood
`changes occur in Pathological Gambling they typically follow winning.
`Problems with gambling are often associated with Antisocial Personality
`Disorder and in Pathological Gambling antisocial behavior is frequent. However,
`in Pathological Gambling any antisocial behavior that occurs is out of despera-
`tion to obtain money to gamble when money is no longer available and legal
`resources have been exhausted. Criminal behavior is rare when the individual has
`money. Also, unlike the individual with Antisocial Personality Disorder, the
`individual with Pathological Gambling usually has a good work history until it
`is disrupted because of the gambling.
`
`Diagnostic criteria for Pathological Gambling
`A. The individual
`is chronically and progressively unable to resist
`pulses to gamble.
`
`im-
`
`305
`
`305
`
`

`

`m—~———.—.——.—.—F____
`Disorders of impulse Control Not Elsewhere Classified
`293
`
`B. Gambling compromises, disrupts, or damages family, personal, and
`vocational pursuits, as indicated by at least three of the following:
`
`{1) arrest for forgery, fraud, embezzlement, or income tax evasion
`due to attempts to obtain money for gambling
`(2) default on debts or other financial responsibilities
`{3} disrupted family or spouse relationship due to gambling
`{4} borrowing of money from illegal sources (loan sharks)
`{5}
`inability to account for loss of money or to produce evidence of
`winning money,
`if this is claimed
`(6}
`loss of work due to absenteeism in order to pursue gambling
`activity
`(7) necessity for another person to provide money to relieve a des-
`perate financial situation
`
`C. The gambling is not due to Antisocial Personality Disorder.
`
`312.32 Kleptomania
`impulses to steal ob—
`The essential feature is a recurrent failure to resist
`jects that are not for immediate use or their monetary value: the objects taken
`are either given away, returned surreptitiously, or kept and hidden. Almost in-
`Variably the individual has enough money to pay for the stolen objects. The
`individual experiences an increasing sense of tension before committing the act
`and intense gratification while committing it. Although the theft does not occur
`when immediate arrest is probable (e.g., in full view of a policeman), it is not
`preplanned, and the chances of apprehension are not fully taken into account.
`The stealing is done without long—term planning and without assistance from,
`or collaboration with, others.
`The diagnosis is not made if the stealing is due to Conduct Disorder or Anti-
`social Personality Disorder.
`
`Associated features. The individual often displays signs of depression,
`anxiety, and guilt over the possibility or actuality of being apprehended and the
`resultant loss of status in society. Often, but not invariably, there are signs of
`personality disturbance.
`
`Age at onset and course. The age at onset may be as early as childhood.
`The condition waxes and wanes and tends to be chronic; how often it "burns
`itself out” is unknown.
`
`Impairment and complications. Impairment is usually due to the legal con-
`sequences of being apprehended, the major complication of the disorder.
`
`Predisposing factors, prevalence, and familial pattern. No informaticin.
`
`Sex ratio. Although the majority of individuals apprehended for shop-
`
`306
`
`306
`
`

`

`294 Diagnostic Categories
`
`lifting are female, only a very small proportion of these individuals have Klepto-
`mania. No data are available on the true sex ratio for the disorder.
`
`Differential diagnosis. In ordinary stealing there is no evidence of a failure
`to resist the impulse; the act is usually planned, and the objects are stolen for
`their immediate use or monetary gain.
`In Malingering, there may be an attempt to simulate the disorder in order
`to avoid criminal prosecution for common thievery. In Conduct Disorder, Anti-
`social Personality Disorder, and manic episodes stealing may occur; however,
`in such cases the act is obviously due to the more pervasive disorder.
`In Schizophrenia stealing may be in response to delusions or hallucinations.
`In Organic Mental Disorders it may occur because of a. failure to appreciate the
`consequences of the act, or because of failure to remember to pay for the object
`that has been taken.
`
`Diagnostic criteria for Kleptornania
`A. Recurrent failure to resist impulses to steal objects that are not for
`immediate use or their monetary value.
`
`B. Increasing sense of tension before c0mmitting the act.
`
`C. An experience of either pleasure or release at the time of committing
`the theft.
`
`D. Stealing is done without long-term planning and assistance from, or
`collaboration with, others.
`
`E. Not due to Conduct Disorder or Antisocial Personality Disorder.
`
`312.33 Pyromania
`fires
`impulses to set
`failure to resist
`The essential features are recurrent
`and intense fascination with setting fires and seeing them burn. Before setting the
`fire, the individual experiences a buildup of tension; and once the fire is under-
`way, he or she experiences intense pleasure or release. Although the fire-setting
`results from a failure to resist an impulse, there may be censiderable advance
`preparation for starting the fire, and the individual may leave obvious clues.
`The diagnosis is not made when fire—setting is due to Conduct Disorder,
`Antisocial Personality Disorder, Schizophrenia, or an Organic Mental Disorder.
`Individuals with the disorder are often recognized as regular "watchers" at
`fires in their neighborhoods, frequently set off false alarms, and show interest
`in fire-fighting paraphernalia. They may be indifferent to the consequences of
`the fire for life or property, or they may get satisfaction from the resulting
`destruction.
`
`Intoxication, Psychosexual Dysfunctions,
`Associated features. Alcohol
`lower than average IQ, chronic personal frustrations, and resentment of authority
`
`307
`
`307
`
`

`

`Disorders of impulse Control Not Elsewhere Classified 295
`
`figures are among the associated features. Cases have been described in which
`the individual was sexually aroused by fires.
`
`Age at onset. Onset is usually in childhood. When it is in adolescence or
`adulthood, the fire-setting tends to be more deliberately destructive.
`
`Course. No information.
`
`Impairment and complications. Impairment is usually due to the legal con-
`sequences of being apprehended, the major complication of the disorder.
`
`Sex ratio. The disorder is diagnosed far more coznmonly in males than in
`females.
`
`Predisposing factors, prevalence, and familial pattern. No information.
`
`Differential diagnosis. Young children’s experimentation and fascination
`with matches, lighters, and fire may be a part of their normal investigation of
`their environment.
`
`In Conduct Disorder, Antisocial Personality Disorder, and the incendiary
`acts of sabotage carried out by political extremists or by “paid torches," fire-
`setting occurs as a deliberate act rather than as a failure to resist an impulse.
`In Schizophrenia, fire-setting may’ be in response to delusions or hallucinations.
`In Organic Mental Disorders, fire-setting may ocrur because of failure to appre-
`ciate the consequences of the act.
`
`Diagnostic criteria for Pyromania
`A. Recurrent failure to resist impulses to set fires.
`
`B.
`
`Increasing sense of tension before setting the fire.
`
`C. An experience of either intense pleasure, gratification, or release at the
`time of committing the act.
`
`D. Lack of motivation, such as monetary gain or sociopolitical ideology,
`for setting fires.
`
`E. Not due to an Organic Mental Disorder, Schizophrenia, Antisocial Per-
`sonality Disorder, or Conduct Disorder.
`
`312.34 Intermittent Explosive Disorder
`The essential features are several discrete episodes of loss of control of
`aggressive impulses that result in serious assault or destruction of property. For
`example, with no or little provocation the individual may suddenly.l start to hit
`strangers and throw furniture. The degree of aggressivity expressed during an
`
`308
`
`308
`
`

`

`296 Diagnostic Categories
`
`episode is grossly out of proportion to any precipitating psychosocial stressor.
`The individual may describe the episodes as ”spells” or “attacks.” The symp-
`toms appear within minutes or hours and, regardless of duration, remit almOst
`as quickly. Genuine regret or self-reproach at the consequences of the action and
`the inability to control the aggressive impulse may follow each episode. There
`are no signs of generalized impulsivity or aggressiveness between the episodes.
`
`The diagnosis is not .made if the loss of control is due to Schizophrenia,
`Antisocial Personality Disorder, or Conduct Disorder. Mild forms of this dis-
`order have, in the past, been called Explosive Personality.
`Prodromal affective or autonomic symptoms may signal an impending
`episode. During the episode there may be subtle changes in sensorium; and
`following the episode there may be partial or spotty amnesia. The behavior is
`usually a surprise to those in the individual’s milieu, and even the afflicted
`individual is often startled by his or her own behavior, sometimes describing the
`events as resulting from a compelling force beyond his or her control, even
`though he or she is willing to accept responsibility for his or her actions.
`
`Associated features. It is not clear to what extent other associated psycho-
`pathology is usually present between episodes.
`
`Often individuals claim hypersensitivity to sensory input such as loud
`noises, rhythmic auditory or visual stimuli, and bright lights. Other features
`suggesting an organic disturbance may be present, such as nonspecific EEG
`abnormalities or minor neurological signs and symptoms thought to reflect sub-
`cortical or limbic system dysfunction. Epilepsy is rarely present, but is never-
`theless more common than in individuals without the disorder. Medical history
`often reveals hyperactive motor behavior and proneness to accident.
`
`Age at onset. The disorder may begin at any stage of life, but more com-
`monly begins in the second or third decade.
`
`Course. No information.
`
`Impairment. Normal social relations may be impaired because of social
`ostracism that results from the unpredictable aggressive behavior.
`
`Complications. Incarceration or chronic hospitalization may result.
`
`Predisposing factors. Any toxic agent, such as alcohol, that may lower the
`threshold for violent outbursts, and conditions conducive to brain dysfunction,
`such as perinatal trauma, infantile seizures, head trauma, and encephalitis may
`predispose to this disorder.
`
`Prevalence. The disorder is apparently very rare.
`
`Sex ratio. The disorder is apparently more common in males than in females.
`The males are likely to be seen in a correctional institution and the females, in
`a mental health facility.
`
`309
`
`309
`
`

`

`Disorders of impulse Control Not Elsewhere Classified 297
`
`Familial pattern. The disorder is apparently more common in family mem-
`bers than in the general population.
`
`Differential diagnosis. An underlying physical disorder, such as a brain
`tumor or epilepsy, may in rare cases cause this syndrome. In such instances the
`diagnosis Intermittent Explosive Disorder should be recorded on Axis I, and the
`physical disorder, on Axis III.
`
`In Antisocial Personality Disorder, outbursts of aggressiveness are common,
`but aggressiveness and impulsivity are also present between the outbursts. In
`Dissociative Disorder any loss of control that occurs invariably follo‘ivs a major
`stressful event, whereas in this disorder there is usuail'}r only a minor or no
`precipitating event. In any case, if the disturbance meets the criteria for Inter-
`mittent Explosive Disorder, this precludes a diagnosis of a Disseciative Disorder.
`In Paranoid Disorder or Schizophrenia, Catatonic Type, there may be out-
`bursts of violent behavior in response to delusions or hallucinations.
`
`Diagnostic criteria for Intermittent Explosive Disorder
`A. Several discrete episodes of loss of control of aggressive impulses
`resulting in serious assault or destruction of property.
`
`B. Behavior that is grossly out of proportion to any precipitating psycho-
`social stressor.
`
`C. Absence of signs of generalized impulsivity or aggressiveness between
`episodes.
`
`D. Not due to Schizophrenia, Antisocial Personality Disorder, or Con-
`duct Disorder.
`
`Isolated Explosive Disorder
`312.35
`The essential feature is a single, discrete episode of failure to resist an im-
`pulse that led to a single, violent, externally directed act, which had a catastrophic
`impact on others and for which the available information does not justify the
`diagnosis of Schizophrenia, Antisocial Personality Disorder, or Conduct Dis-
`order. An example would be an individual who for no apparent reason sud-
`denly began shooting at total strangers in a fit of rage and then shot himself.
`In the past this disorder was referred to as ”catathymic crisis."
`
`In some cases additional in formation indicates an underlying psychosis, such
`as Schizophrenia, Paranoid Type, which would then preempt this diagnosis. As
`with Intermittent Explosive Disorder, this category is defined behaviorally. In
`those rare instances in which an underlying organic etiology is revealed, such
`as a brain tumor, this would be an additional diagnosis, coded on Axis 111.
`Other features of this disorder are similar to those of Intermittent Explosive
`Disorder.
`
`310
`
`310
`
`

`

`298 Diagnostic Categories
`
`Diagnostic criteria for Isolated Explosive Disorder
`A. A single, discrete episode in which failure to resist an impulse led
`to a single, violent, externally directed act that had a catastrophic impact
`on others.
`
`B. The degree of aggressivity expressed during the episode was grossly
`out of proportion to any precipitating psychosocial stressor.
`
`C. Before the episode there were no signs of generalized impulsivity or
`aggressiveness.
`
`D. Not due to Schizophrenia, Antisocial Personality Disorder, or Conduct
`Disorder.
`
`312.39 Atypical Impulse Control Disorder
`This category is for Disorders of Impulse Control that cannot be classified
`elsewhere.
`
`311
`
`311
`
`

`

`Adjustment Disorder
`
`feature is a maladaptive reaction to an identifiable psycho-
`The essential
`social stressor, that occurs within three months after the onset of the stressor.
`The maladaptive nature of the reaction is indicated by either impairment in so-
`cial or occupational functioning or symptoms that are in excess of a normal
`and expected reaction to the stressor. The disturbance is not merely one in—
`stance of a pattern of overreaction to a stre'ssor or an exacerbation of one of
`the mental disorders previously described. It is assumed that the disturbance will
`eventually remit after the stressor ceases or, if the stressor persists, when a new
`level of adaptation is achieved. This category should not be used if the dis-
`turbance meets the criteria for a specific disorder, such as an Anxiety or Affective
`Disorder.
`
`The stressors may be single, such as divorce, or multiple, such as marked
`business difficulties and marital problems. They may be recurrent, as with sea-
`sonal business crises, or continuous, as with chronic illness or residence in a de-
`teriorating neighborhood. They can occur in a family setting, e.g., in discordant
`intrafamilial relationships. They may affect only the individual, e.g., the psycho-
`logical reaction to a physical illness, or they may affect a group or community,
`e.g., a natural disaster, or persecution based on racial, social, religious, or other
`group affiliation. Some stressors are associated with specific developmental
`stages, such as going to school, leaving the parental home, getting married, be-
`coming a parent, failing to attain Occupational goals, and retirement.
`The severity of the stressor and the specific stressor may be noted on Axis
`W (p- 26). The severity of a specific stressor is affected by its duration, timing,
`and context in a person’s life. For example, the stress of losing a parent is differ-
`ent for a child and an adult.
`
`The severity of the reaction is not completely predictable from the severity
`of the stressor. Individuals who are particularly vulnerable may have a more
`severe form of the disorder following only a mild or moderate stressor, whereas
`others may have only a mild form of the disorder in response to a marked and
`continuing stressor.
`Types. The manifestations of the disorder are varied. Each specific type
`represents a predominant clinical picture (p. 301), many of which are partial syn—
`dromes of specific disorders. For example, Adjustment Disorder with Depressed
`Mood is manifested by an incomplete depressive syndrome in response to a
`psychosocial stressor.
`
`Age at onset. Adjustment Disorder may begin at any age.
`
`Course. By definition the disturbance begins within three months of the
`
`299
`
`312
`
`312
`
`

`

`300 Diagnostic Categories
`—-—-———.___.___._______
`
`onset of the stressor. If the stressor is a discrete event, such as being fired from
`a job, the onset of the disturbance is usually within a few days, and the dura-
`tion is relatively brief—no more than a few months. If the stressor continues, as
`with a chronic physical illness, the duration may be much longer until a new
`level of adaptation is achieved.
`
`Predisposing factors. A preexisting Personality Disorder or Organic Mental
`Disorder may increase an individual’s vulnerability to stress and predispose to
`the development of Adjustment Disorder.
`
`Prevalence. The disorder is apparently common.
`
`Sex ratio and familial pattern. No information.
`
`Differential diagnosis. In Conditions Not Attributable to a Mental Dis~
`order (V codes), such as Other Interpersonal Problem or Phase of Life Problem
`or Other Life Circumstance Problem, there is neither impairment in social or
`occupational functioning nor symptoms that are in excess of a normal and
`expectable reaction to the stressor. No absolute guidelines are available to aid in
`this fundamental distinction, so clinical judgment will often be required.
`Personality Disorders are often repeatedly exacerbated by stress, in which
`case the additional diagnosis of Adjustment Disorder is not made. However, if
`new features are seen in response to a stressor—such as depressed mood in an
`individual with Paranoid Personality Disorder who has never been bothered by
`depression—then the additional diagnosis of Adjustment Disorder may be ap-
`propriate.
`
`In Psychological Factors Affecting Physical Condition the individual may be
`reacting to a psychosocial stressor, but the predominant symptomatology is a
`physical condition or disorder.
`
`Diagnostic criteria for Adjustment Disorder
`A. A maladaptive reaction to an identifiable psychosocial stressor,
`occurs within three months of the onset of the stressor.
`
`that
`
`B. The maladaptive nature of the reaction is indicated by either of the
`following:
`
`(1)
`
`impairment in social or occupational functioning
`
`(2} symptoms that are in excess of a normal and expectable reaction
`to the stressor
`
`C. The disturbance is not merely one instance of a pattern of overreac-
`tion to stress or an exacerbation of one of the mental disorders previously
`described.
`
`313
`
`313
`
`

`

`Adjustment Disorder
`
`301
`
`the
`the disturbance will eventually remit after
`is assumed that
`It
`D.
`stressor ceases or,
`if the stressor persists, when a new level of adaptation
`is achieved.
`
`E. The disturbance does not meet the criteria for any of the specific
`disorders listed previously or for Uncomplicated Bereavement.
`
`TYPES OF ADIUSTMENT DISORDER. Code predominant symptoms.
`
`309.00 Adjustment Disorder with Depressed Mood
`This category should he used when the predominant manifestation involves
`such symptoms as depressed mood, tearfulness, and hopelessness. The major
`differential is with Major Depression and Uncomplicated Bereavement.
`
`309.24 Adjustment Disorder with Anxious Mood
`This category should be u5ed when the predominant manifestation involves
`such symptoms as nervousness, worry, and jitteriness. The major differential
`is with Anxiety Disorders.
`
`309.28 Adjustment Disorder with Mixed Emotional Features
`This category should be used when the predominant manifestation involves
`various combinations of depression and anxiety or other emotions. The major
`differential is with Depressive and Anxiety Disorders. An example would be an
`adolescent, after moving away from home and parental sopervision, who reacts
`with ambivalence, depression, anger, and signs of increased dependency.
`
`309.30 Adjustment Disorder with Disturbance of Conduct
`This category should be used when the predominant manifestation involves
`conduct in which there is violation of the rights of others or of major age-
`appropriate societal norms and rules. Examples:
`truancy, vandalism, reckless
`driving, fighting, defaulting on legal responsibilities. The major differential is
`with Conduct Disorder and Antisocial Personality Disorder.
`
`309.40 Adjustment Disorder with Mixed Disturbance of Emotions and Conduct
`This category should be used when the predominant manifestation involves
`both emot